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Immigration Reform: A Second Chance for Undocumented Immigrant Health?

When the Affordable Care Act was signed into law in March of 2010, many immigration advocates were disappointed that the bill left undocumented immigrants out in the cold. While the law kickstarts the process of bridging the gap for millions of uninsured Americans, specific language was written into the legislation to bar undocumented immigrants from being “eligible for public insurance or any type of private coverage obtained through exchanges.” At the time of the bill’s signing, approximately 7 million out of an estimated 11 million undocumented immigrants in the US were without insurance, and many of whom were living in poverty. These numbers are only expected to increase [1]. With immigration reform highly visible in Obama’s second term, immigration advocates are now viewing this as a second chance to address a growing public health concern.

Immigration rally in Miami

Immigration reform that includes either a path to citizenship or gaining recognition as legal residents would “open the door” for unauthorized immigrants to health insurance and ultimately better health care. But any consideration of immigration reform engenders debate that can quickly turn divisive. Do undocumented immigrants have a right to citizenship? How would “amnesty” affect the economy, employment, social services and other federal programs in the US? Would subsidizing health insurance for 7 million additional people increase costs to the government? Or would it drive costs, such as health insurance premiums, down? This has been suggested because immigrants, both legal and undocumented, incur less heathcare costs (although, this might be a reflection of their lack of access to healthcare to begin with), while undocumented immigrants tend to be young and healthy. This of course doesn’t reflect the reality for all undocumented immigrants who make up a significant proportion of the migrant labor workforce–a group associated with significantly poor health [2].

One of the public health fears that citizens who want stricter border control have is that undocumented immigrants are transporting or spreading communicable diseases like HIV or leprosy as Lou Dobbs once proclaimed. Seemingly confirming these fears, last November there were reports of “a man from Nepal who carries a severe multi-drug resistant form of tuberculosis was detained by Border Patrol when he illegally crossed into the country near McAllen after staying in Mexico for a week.” Assuming that undocumented immigrants are bringing diseases into the country than increasing border security does nothing to deal with diseases already potentially in the country. Bringing undocumented immigrants into the healthcare fold would.

It is often noted that since undocumented immigrants lack insurance and access to healthcare, many forgo routine, preventative checkups with primary care physicians. Instead, many undocumented immigrants receive healthcare services from hospital emergency rooms–often times waiting until an injury or illness becomes serious before seeking treatment. This puts a burden on the healthcare system since emergency room visits are expensive and are paid for by the government through programs like Medicaid. Consistent with entering care later, a recent study in PLOS One found that undocumented Hispanic immigrants that sought care at a HIV free clinic in Houston presented with features of HIV infection that were more advanced than their legal resident counterparts [3]. Although, once in care undocumented Hispanic immigrants fared just as well, if not better, than legal residents with HIV.

Making matters worse, fear of deportation also represents a psychological barrier for unauthorized immigrants to seek healthcare [4]. A smaller scale study reports that the impact of this fear is twofold as it not only prevents some from seeking treatment but also exerts mental health stress [5]. Furthermore, these effects also extend to legal immigrants who feared deportation as a result of unfamiliarity with US immigration policies.

As of this week, immigration reform seems tantalizingly close (although, we all know legislative looks can be deceiving). The bipartisan “Gang of Eight” expect a comprehensive bill overhauling immigration by the end of this week. Some of the details being hammered out are agreements between unions and business for a “low-skilled worker visa” and if and how a pathway to citizenship would be implemented (undocumented immigrants could be waiting as long as 8 to 10 years before they can even begin the process of naturalization). Immigrant communities and advocates, however, will not be sitting idly on the sidelines as they plan to rally in Washington D.C. on Wednesday.